Syncope

Internal Medicine
LEC 3
(4TH stage dentistry)

Syncope
A Lecture by Dr. Ghassan M. Jasim
 Syncope is defined as a transient, self-limited loss of consciousness with an inability to

maintain postural tone that is followed by spontaneous recovery. This definition excludes
seizures, coma, shock, or other states of altered consciousness.
 loss of consciousness in syncope is due to reduced cerebral perfusion.
 Presyncope’ refers to lightheadedness in which the individual thinks he or she may black
out.
 Syncope affects around 20% of the population at some time and accounts for more than
5% of hospital admissions.
 Dizziness and presyncope are very common in old age.
Classifications
There are three principal mechanisms that underlie recurrent presyncope or syncope:
 Cardiac syncope due to mechanical cardiac dysfunction or arrhythmia
 Neurocardiogenic syncope, in which an abnormal autonomic reflex causes
bradycardia and/or hypotension
 Postural hypotension, in which physiological peripheral vasoconstriction on
standing is impaired, lead to hypotension.
Cardiac (cardiopulmonary) syncope
 may be due to vascular disease, cardiomyopathy, arrhythmia, or valvular dysfunction

 predicts a worse short-term and long-term prognosis.
 Obtaining an initial ECG is mandatory if any of these causes are possible for the differen-
tial diagnosis.
1
Neurocardiogenic syncope
 This encompasses a family of syndromes in which bradycardia and/or hypo-
tension occur because of a series of abnormal autonomic reflexes.
 Examples: Situational syncope, vasovagal syncope, Hypersensitive Ca-

rotid Sinus Syndrome
Situational syncope
• This is the collective name given to some variants of neurocardiogenic syncope that oc-
cur in the presence of identifiable triggers (e.g. cough syncope, micturition syncope).
• These stimuli result in autonomic reflexes with a vasodepressor response, ultimately lead-
ing to transient cerebral hypotension. These are not life-threatening but can cause mor-
bidity.
Vasovagal syncope
• is the most common type in young adults but can occur at any age. This is normally trig-
gered by a reduction in venous return due to prolonged standing, excessive heat or a large
meal, fear, emotional stress, or pain (eg, after a needlestick).
• Autonomic symptoms are predominant. Classically, nausea, diaphoresis, fading or
"graying out" of vision, epigastric discomfort, and light-headedness precede syncope by
a few minutes.
• It is not life threatening and occurs sporadically.
• It is mediated by the Bezold–Jarisch reflex, in which a combination of sympathetic acti-
vation, and reduced venous return due to an impaired vasoconstrictor response to standing,
leads to vigorous contraction of relatively under-filled ventricles. This stimulates ventric-
ular mechanoreceptors, producing parasympathetic (vagal) activation and sympathetic
withdrawal, causing bradycardia, vasodilatation or both.
• Head-up tilt-table testing is a provocation test used to establish the diagnosis, and involves
positioning the patient supine on a padded table that is then tilted to an angle of 60–70° for
up to 45 minutes, while the ECG and BP responses are monitored. A positive test is char-
acterised by bradycardia (cardio-inhibitory response) and/or hypotension (vasodepressor
response) associated with typical symptoms.
2
Differential diagnosis of syncope:
• History-taking, from the patient or a witness, is the key to establishing a
diagnosis. Attention should be paid to:
• Potential triggers (e.g. medication, exertion, posture),
• The victim’s appearance (e.g. colour, seizure activity),
• The duration of the episode and the speed of recovery
• Postural hypotension is normally obvious from the history, with presyncope
or, less commonly, syncope, occurring within a few seconds of standing.
3
POSTURAL HYPOTENSION (ORTHOSTATIC HYPOTENSION)
o Postural hypotension (orthostatic hypotension, OH) is a fall in systemic arte-
rial pressure on assumption of upright posture.
o It is defined as a sustained drop in systolic (>20 mmHg) or diastolic (>10
mmHg) blood pressure within 3 minutes of standing.
o Symptoms of postural hypotension are dimming or loss of vision, light headed-
ness, diaphoresis, nausea, pallor and weakness. Syncope may result if cerebral
perfusion is impaired.
o Postural hypotension is generally due to defective postural reflexes, hypovole-
mia or drugs. A history of medications, previous postural syncope, diabetes and
causes precipitating hypovolemia must be obtained before the procedure

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Internal Medicine

(4TH stage dentistry)

 Syncope is defined as a transient, self-limited loss of consciousness with an inability to

Cardiac (cardiopulmonary) syncope

 may be due to vascular disease, cardiomyopathy, arrhythmia, or valvular dysfunction

 Examples: Situational syncope, vasovagal syncope, Hypersensitive Ca-

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